Claims Operations Lead: Facets & BPM Excellence

UST; Taguig; On-site; PHP 3,781,000 - 6,301,000; Full time

Job summary

UST seeks a Claims Lead for BPM operations supporting a U.S. healthcare payer. You will oversee end-to-end claims processing, governance, workforce management, and SLA adherence with a focus on Facets adjudication. Ideal candidates have 8+ years in U.S.

Healthcare Claims Operations, 2+ years in a Team Lead role, and strong leadership for offshore delivery models. Blue Card/Blue Plan experience is a plus. Responsibilities include managing production, performance metrics, quality assurance, and

Qualifications

• Graduate degree required.
• 8+ years of experience in U.S. Healthcare Claims Operations.
• Minimum 2+ years in a Team Lead or Operations Lead role.
• Strong Facets expertise is required.
• Blue Plan/BlueCard experience an advantage.

Responsibilities

• Lead end-to-end claims delivery within the Facets adjudication environment.
• Manage daily production, work allocation, workload balancing, and throughput.
• Monitor inventory, aging, productivity, and operational performance across multiple queues.
• Ensure adherence to KPIs, SLAs, and productivity targets.
• Drive consistency and efficiency in claims processing activities.
• Serve as the functional lead for claims adjudication and workflow management.
• Resolve complex claims involving pricing discrepancies, benefit interpretation issues, retro eligibility scenarios, and adjusted claims processing.
• Ensure alignment with Facets configurations, edits, and system-driven outcomes.
• Partner with stakeholders to identify gaps and implement corrective actions.
• Ensure compliance with coding standards, payment policies, payer edits, and governance requirements.
• Lead audit reviews, calibration sessions, root cause analysis, and defect prevention initiatives.
• Monitor accuracy across payment outcomes, compliance measures, and operational metrics.
• Address systemic issues related to pricing, eligibility, configuration, and provider data.
• Drive continuous improvement initiatives to enhance first-pass accuracy and reduce rework.

Skills

Facets expertise

Claims management

Service level management

Stakeholder management

Education

Graduate degree

Job description

UST seeks a Claims Lead for BPM operations supporting a U.S. healthcare payer. You will oversee end-to-end claims processing, governance, workforce management, and SLA adherence with a focus on Facets adjudication. Ideal candidates have 8+ years in U.S.

Healthcare Claims Operations, 2+ years in a Team Lead role, and strong leadership for offshore delivery models. Blue Card/Blue Plan experience is a plus. Responsibilities include managing production, performance metrics, quality assurance, and